Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0067, written 3 Mar 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2022 |
|---|---|
| Reference | 2022-0067 |
| Deceased | Alan Hodgson |
| Coroner | Derek Winter DL |
| Coroner area | City of Sunderland |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | South Tyneside and Sunderland NHS Foundation Trust · County Durham and Darlington NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Derek Winter DL Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive of County Durham and Darlington NHS Foundation Trust (thereafter to be referred to as The Trust) 1 CORONER I am Derek Winter DL, Senior Coroner for the City of Sunderland 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST On 16th June 2021 I commenced an Investigation into the death of Mr Alan Hodgson, who was born on 20th January 1959 and died in Sunderland Royal Hospital on 14th January 2021. The Investigation concluded at the end of the Inquest on 17th February 2022. The medical cause of death was confirmed as: - Ia Multi Organ Dysfunction Syndrome Ib Ischaemic Colon Ic Severe Vascular Occlusive Disease II COVID 19 Positive 4 CIRCUMSTANCES OF THE DEATH Alan Hodgson died at Sunderland Royal Hospital on 14th January 2021. The severity of his condition had not been recognised despite numerous interactions with him, all of which were compounded by a delay in reporting and acting upon a partial scan. The Coroner recorded a conclusion of Natural causes contributed to by neglect. 5 CORONER’S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. Office of HM Coroner for the City of Sunderland, City Hall, Plater Way, Sunderland, SR1 3AA Tel 0191 5617843 | Fax 0191 5537803 www.sunderlandcoroner.co.uk The MATTERS OF CONCERN are, as follows: – (1) Signing and administration of opiate analgesia to a patient without any evidence of ascertaining why such analgesia was required, and if it was appropriate; (2) Failure by the on-call Registrar to review a patient in the early hours of the morning when called for advice by the FY1 doctor; (3) Failure by a Consultant Physician to follow an established Vascular Pathway despite clearly recognising the correct diagnosis of acute lower limb ischaemia; (4) Poor communication between medical and radiology doctors resulting in: a) delays in CTA being performed; b) inadequate imaging being performed; and c) a complete lack of urgency in reporting the findings of the CTA to the requesting doctors. (5) Very poor standard of care in respect of continuity of care; leaving the vascular referral to Sunderland to a very junior doctor on-call who did not even know the patient; (6) An insufficiently robust review by The Trust of the circumstance leading to the death of Mr Alan Hodgson and of the lessons to be learnt from it, i.e. an insufficient review of the vascular pathway, including its dissemination, awareness and continuous training to improve the importance of the rapid escalation of care against the background of effective communications and handovers between staff to promote holistic patient care. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th April 2022. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: - • Family and their Solicitors and Counsel • North East Ambulance Service • Secretary of State for Health and Social Care • Care Quality Commission • Risk and Inquest Manager, South Tyneside and Sunderland NHS Foundation Trust I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated this 3rd day of March 2022 Signature Senior Coroner for the City of Sunderland
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